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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, 0 q L U Telephone (209) 466-6781 GATE ISSUED / PERh1IT EXPIRES 1'Y EAR FROM DATE ISSUED (Complete in Triplicate) � A li h i hereby made h n pp i.cat o s e y a e to the San Joaquin Local Health District fora permit to construct and/or install the work herein --described. This application �s made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations fof the San Joaquin ocal Health District, j� r /t ,[�l Job Address L Also �t Subdivision Name .` - � �T VJ �"� ',v v Owner's Name Address 56 14 Phone Contractor's Name License No. � �L� - PhoneTZ g f p TYPE OF WELL/PUMP WORK: � NE4J�WELL 1` � ..%WELL REPLACEMENT ❑ UC DESTRTION ❑ r^ - 4 ` Y PUMP`INSTALLATIJN;. SYSTEM REPAIR ❑ OTHER ❑ V" { DISTANCE TO NEAREST: SEPTIC TANK �Sd ={ ' SEWERiLINES � r.� DISPOSAL FLD. rte[ PROP. LINE ? FOUNDATION AGRICULTURE WELL D r . ' OTHER,WELL PITS/SUMPS INTENDEDiUSE 4 TYPE bF WELL `PROBLEM AREA ` CONSTRUCTION SPECIFIGATiONS' If Industrial '' "^ r;E] OpenISottom`< ❑ Manteca Dia, of Wel l'Excavation Domestic/Privatey ; Dia. of Well Casing Gravel Pack ❑ Trac Public I ❑ 1: 0the; ❑ Delta Type of Casing F, Irrigation Approx.- ❑ Eastern ❑ Cathodic Protection Depth; Specifications ' Geophysical Depth of Grout Seal ❑ Type of Grout —.S_£r yea JE wC FlOther Surface Seal Installed by 0 A2^1,e i'L Repair Work Done ❑ Type of Pump " H.P. State Work Done �— Well Destruction ❑ Well Diameter Sealing Material (top 50') , Depth Filler Material (Below 50') i ��Y M � ■Ili Il•ii 1 iii TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is rn available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: j�Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth 'f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfgi Capacity Method of Disposal [ SEWAGE SYSTEM Distance�to nearest: Well dFoundation Property Line DESTRUCTION LEACHING LINE U No. & Length of..Iines Total length/size FILTER BED ❑ Distance tc nearest: Well Foundation Property'Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance! to nearest: Well Foundat5on Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's silgnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not emplJoy any p rson in such manner as'to become subject to workman5 compensation laws of California. Contractor's hiring or sub-contr ctin si ature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall 'plo p ons subject to workman's compensation laws of California." The applic ust 1 for re spec ions. Complete drawing or re erse side. Signed X Title: Date: �� f FOR MENT USE ONLY Application Accepted by I Area � 3 ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ><M—anteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 f Applicant - Return all copies to:64nvYironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE SASE AMOUNT .DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. fNFD EH 13-24 REV. 10/82 10/82 500 14-26